Skip to main content
Version: 2.2

Payer MRF Data

SchemaMethodology

CLD pulls Payer MRF data from Core Rates and Core Rates Physician Groups.

Core Rates — Data‑Source Overview (Technical Documentation)​

Core Rates is a monthly de‑normalized dimensional table (core_rates) written to each schema public_YYYY_MM in Trino.
It contains institutional and associated professional in‑network negotiated rates for hospitals, hospital units, ASCs, imaging centers, labs, FQHCs and RHCs.

Data Scope​

  • Providers: Institutional entities only; individual practitioners are excluded.
  • Codes & Rates: No exclusions on billing codes, billing classes or negotiation arrangements; professional fees tied to the institutional providers above.
  • Clinically Implausible Filter: For every non‑hospital taxonomy we exclude codes outside the top 99 % of procedures billed (CPT & HCPCS) to remove nonsensical rates.
  • Records with negotiated_rate = 0 are dropped.

Payer & File Inclusion Logic​

For each state, Core Rates keeps: United Healthcare, Cigna, Aetna, the in‑state BCBS affiliate (or Anthem), BlueCard PPO, plus any payer with meaningful commercial market share.
If a payer’s files are unlabeled, we select the five largest file‑networks with the most plans; only provider rates in states where that payer holds market share are included.

Core Rates Sense & Outlier Management (Not Used in Clear Rates)​

core_rates_sense is a slimmed subset that powers Payer Data Rate Sense.
Key differences: it replaces product_network_label with network_array, removes clinically implausible rates entirely, appends extra provider/billing metadata, and introduces rate_is_outlier.

A rate is flagged rate_is_outlier = TRUE when any of the following hold (Oct 2024 rules):

  1. <10 % or >1000 % of the Medicare reference price (when available)
  2. >$500 k on an outpatient (non‑drug) code
  3. >$2.5 M on an inpatient (non‑drug) code
  4. <10 % or >1000 % of ASP on a drug code, or if Aetna posted the drug code with modifiers 52–56
  5. >100 % on a percentage‑negotiated rate

Physician Groups Core Rates — Data‑Source Overview (Technical Documentation)​

Physician Groups Core Rates (core_rates_physician_groups) is a parallel monthly de‑normalized table dedicated to professional in‑network rates at the provider‑group level (groups that bill under ‘Allopathic & Osteopathic Physicians’).

Data Scope​

  • Providers: Groups with physician NPIs; individual practitioner NPIs are excluded.
  • Codes & Rates: All billing codes / negotiation arrangements, but only professional classes are pulled in.
  • Clinically Implausible Filter: Same 99 % claims‑based rule as Core Rates; implausible codes are omitted.
  • Records with negotiated_rate = 0 are excluded.

Payer & File Inclusion Logic​

Selection mirrors Core Rates but focuses on payers with commercial market share in each state (plus the national trio and BCBS/BlueCard). For unlabeled payers we again choose the five largest file‑networks.

Groups appear only in their primary state as defined by the group NPI (or by the NPI most commonly linked to an EIN).

On this page: